Employment Application

Step 1 of 3

This employment application is provided by PERENNIAL ANGELS HOMECARE, and complies with federal and state laws against discrimination. Provide all information requested by printing in ink or typing.

General Information

Name*

FirstMiddleLast

Home Phone*

Other Phone

Email*

Are You Legally entitled to work in the U.S.?*

Yes

No

Your Current Address*

Street AddressAddress Line 2CityStateZIP Code

Position

Position or Type of Employment Desired*

Are you able to perform the essential functions of the job you are applying for, with or without reasonable accommodation?*

Yes

No

Will Accept:*

Part-Time

Full-Time

Temporary

Shift:*

Day

Swing

Graveyard

Rotating

Salary Desired*

Date Available*

Education & Training

High School Graduate Or General Education (GED) Test Passed?*

Yes

No

If no, list the highest grade completed below

Highest Grade Completed*

COLLEGE, BUSINESS SCHOOL, or MILITARY

Name & Location

Start Date

End Date

Credits Earned

Quarterly, Semester hours or other (please specify)

Degree and Year

Major or Subject

COLLEGE, BUSINESS SCHOOL, or MILITARY

Name & Location

Start Date

End Date

Credits Earned

Quarterly, Semester hours or other (please specify)

Degree and Year

Major or Subject

COLLEGE, BUSINESS SCHOOL, or MILITARY

Name & Location

Start Date

End Date

Credits Earned

Quarterly, Semester hours or other (please specify)

Degree and Year

Major or Subject

COLLEGE, BUSINESS SCHOOL, or MILITARY

Name & Location

Start Date

End Date

Credits Earned

Quarterly, Semester hours or other (please specify)

Degree and Year

Major or Subject

Occupational License, Certificate or Registration

Number

Where Issued & Expiration Date

Occupational License, Certificate or Registration

Number

Where Issued & Expiration Date

Occupational License, Certificate or Registration

Number

Where Issued & Expiration Date

Languages Read, Written or Spoken Fluently Other Than English

Veteran Information

Branch Of Service

Date of Entry

Date of Discharge

Any Special Skills?

Work Experience

(Most Recent First - Include voluntary work and military experience) Describe your work experience in detail for the past ten (10) years minimally. Use a separate block to describe each position. Include military service (indicate rank) and job-related volunteer work, if applicable. Indicate number of employees supervised. Provide an explanation of any gaps in employment.

Employer 1

Phone

Address

Job Title

Number of Employees Supervised

Start Date & End Date (Month/Year)

Hours Per Week

Last Salary

Supervisor Name

Reason For Leaving

Specific Duties

Maximum 1000 characters

May We Contact This Employer?

Yes

No

Employer 2

Phone

Address

Job Title

Number of Employees Supervised

Start Date & End Date (Month/Year)

Hours Per Week

Last Salary

Supervisor Name

Reason For Leaving

Specific Duties

Maximum 1000 characters

May We Contact This Employer?

Yes

No

Employer 3

Phone

Address

Job Title

Number of Employees Supervised

Start Date & End Date (Month/Year)

Hours Per Week

Last Salary

Supervisor Name

Reason For Leaving

Specific Duties

Maximum 1000 characters

May We Contact This Employer?

Yes

No

References

Reference 1 Name (Professional)*

Company*

Job Title*

Email*

Phone*

ALT Phone

Reference 2 Name (Professional)*

Company*

Job Title*

Email*

Phone*

ALT Phone

Reference 3 Name (Personal)*

Company*

Job Title*

Email*

Phone*

ALT Phone

Document Upload

Please Upload A Copy of Your Driver's License

Please Upload A Copy of Your High School Diploma/Degrees

Drop files here or

Please Upload A Copy of Your Certifications/Licenses

Drop files here or

Consent for Pre-Employment Reference/Background Check

I recognize that any offer of employment made to me by PERENNIAL ANGELS HOMECARE is conditional upon reference and background checks which are acceptable to the Agency, and that information obtained during this process may result in my not being employed by PERENNIAL ANGELS HOMECARE. I understand that PERENNIAL ANGELS HOMECARE and/or its designated representatives will conduct pre-employment reference checks thoroughly and within the confines of all applicable state and federal laws.

I understand that PERENNIAL ANGELS HOMECARE will maintain any information obtained as a result of my signing this Consent in a confidential file in the Human Resources Department.

I understand that a reference and/or background check is being performed as part of the process to evaluate me prior to any offer of employment, and is not conducted for any other purpose. I authorize PERENNIAL ANGELS HOMECARE, or its designated representative presenting this consent or a photocopy thereof, to obtain the following records and information in connection with my application for employment with the Agency insofar as the records and information are relevant to the position for which I am applying:

Criminal History and Convictions

Motor Vehicle Operation

Certification and Licensing

Educational History and Credentials

Employment Eligibility

Prior Employment Information

Personal References

Professional References

If the position for which I am applying specifically requires a personal credit history acceptable to PERENNIAL ANGELS HOMECARE, I understand that I will be required to sign a separate Fair Credit Reporting Act Consumer Report Disclosure authorizing PERENNIAL ANGELS HOMECARE to obtain the same. No personal credit history will be obtained by PERENNIAL ANGELS HOMECARE without this authorization.

I authorize all persons who are the custodians of these records, or who may have information relevant to my application for employment to provide records or disclose such information to PERENNIAL ANGELS HOMECARE and/or its designated representative.

I release PERENNIAL ANGELS HOMECARE, its employees, designated representatives, agents, officers and trustees, as well as all persons or entities that provide records or disclose information, from any and all claims of liability or damage due to either the procurement or the true and accurate disclosure of such records or information.

I certify the information contained in this application is true, correct, and complete. I attest that I have never been shown by credible evidence (e.g. a court or jury, a department investigation, or other reliable evidence) to have abused, neglected, sexually assaulted, exploited, or deprived any person or to have subjected any person to serious injury as a result of intentional or grossly negligent misconduct. I understand that, if employed, false statements or misrepresentations reported on this application may be considered sufficient cause for dismissal.

Digital Signature*

By typing your full name you are acknowledging the above statements and digitally signing this application and consent for a pre-employment background check.